Department of Internal

Medicine
Christian University of Indonesia

MORNING REPORT
January, 29th 2016
TEAM 2

Mr. A. 58 YO
CC : Shortness of breath
Findings
Dyspnoe, coughing 2 mounths ago, nausea and vomiting, appetite
decrease, night sweat
GCS :E4V5M6, BP: 150/80, PR 78 x, T : 36,5 oC, RR: 32x
Eye : Pale Conjungtiva -/-, Sclera icteric -/THT : Normal
Neck : Lymph Nodes not Enlarged
JVP : distended (-), 5-2 cmH2O
THORAX

I : Symmetrical chest wall movement, ictus cordis (-) , retraction intercosta.

Pal: Vocal fremitus asimetric
Per: Dal /Sonor
Aus: Basic breath sound vesical, ronchi +/+, wheezing -/-. S1 and S2
reguler, gallop (-), murmur (-)
ABDOMEN

Ins : Flat
Aus : Bowel sound (+) 3times/minute
Per : Timpani on 9 regions, percussion tenderness (-)
Pal : Supel, Pressure pain (-)
Extremity : pitting oedem (-), warm acral, CRT < 2

Assesment
Efusion
pleural et
causa TB
pulmonal

Therapy
MM/
1. Ceftizoxime 2x1 gr
(iv)
2. OBH 3x1 C (po)
3. Ranitidine 2x1 (iv)
4. B. Comp 2x1 (po)

Planning
Pleural punction
Diet : high calories high protein
O2 NK 3-4 lpm
IVFD : I RL+ I Futrolit / 24
hours
Check BTA, LED,
SGOT/SGPT, Ureum,
Creatinin,

Subjective Data
Name
: Mr. A, 58 years old
TC : Friday , January 29th 2016
CC
: Shortness of breath

Anamnesis
Main symptom
: Shortness of breath
Additional symptom :
Patient was came with headache since 5 days
before admittance to hospital. Patients complain
of headache suddenly. Nausea (+), vomiting (-),
urinate has normal, Not defecate since 5 days
ago. cough (-), fever ( -).

Past Medical History and Treatment

-

Family History
-

Social History
-

Objective Data

Appearance : Mild Illness

GCS :E4V5M6
BP: 150/80
PR 78 x
T : 36,5oC
RR: 32x
Eye: Pale conjunctiva -/- , sclera icteric -/Ear, Nose, throat : normal
Neck : lymph nodes not enlarged
JVP : distended (-), 5-2 cmH2O

Thorax.

I : Symmetrical chest wall movement, ictus cordis (-) , retraction intercosta.

Pal: Vocal fremitus asimetric
Per: Dal /Sonor

Aus: Basic breath sound vesical, ronchi +/+, wheezing -/-. S1 and S2 reguler, gallop (-), murmur (-)
Abdomen.
-

Ins Ins : Flat

Aus : Bowel sound (+) 3times/minute

Per : Timpani on 9 regions, percussion tenderness (-)

Pal : Supel, Pressure pain (-)

Extremity
- Pitting oedem (-), warm acral, CRT < 2

Assessment
Efusion pleural et causa TB pulmonal

Therapy
MM/
1.Ceftizoxime 2x1 gr (iv)
2.OBH 3x1 C (po)
3.Ranitidine 2x1 (iv)
4.B. Comp 2x1 (po)

Planning
Pleural punction
Diet : high calories high protein
O2 NK 3-4 lpm
IVFD : I RL+ I Futrolit / 24 hours
Check BTA, LED, SGOT/SGPT, Ureum, Creatinin

Department of Internal
Medicine
Christian University of Indonesia

Thank You